OBJECTIVES: Risk of cardiovascular disease, retinopathy, nephropathy, and neuropathy increases substantially when HbA1c>7% (suboptimal glycemic control), but timely therapy intensification may reduce risk. When HbA1c>9% (very poor control) AACE recommends that triple therapy (asymptomatic patients) or insulin (symptomatic patients) be initiated to reach HbA1c≤6.5% for patients without concurrent illness and at low hypoglycemic risk. Clinical inertia (failure to intensify therapy in a timely manner) leads to poor glycemic control. The objective of this study was to examine time to treatment modifications in patients with HbA1c≥9%.
METHODS: Medical, laboratory, and pharmacy claims data for Humana’s fully insured commercial and Medicare membership were used for this study. Patients with T2DM with first HbA1c≥9% date (index-date) between Jan 1, 2008–Dec. 31, 2009 were identified. Baseline characteristics were obtained within 12 months preceding the index-date. Treatment modification was defined as addition or switch of an antidiabetic drug class. Study outcome (delay in treatment modification) was assessed as the days until modification within the 36-months post-index period.
RESULTS: There were 8,464 patients identified (mean age 66 years, 48% male, 82% from the southern US, mean Deyo-Charlson Comorbidity Index 2.54, mean Diabetes Complications Severity Index 2.17). Approximately 83% of patients experienced modification within 36 months; 47% within 90 days of HbA1c≥9% index date, 7% between 91-180 days, 5% between 181-365 days, while 24% were >365 days. Around 20% of patients received insulin as a modification. Although the proportion of patients receiving triple therapy (≥3 classes) was still low (23%) at 12 months post-index, it increased from 10% at baseline.
CONCLUSIONS: Many patients in poor control receive insufficient therapy as recommended by treatment guidelines. Even though additional agents were added for some patients, those receiving insulin or triple therapy were low. For patients with HbA1c≥9%, prompt treatment intensification is needed to improve glycemic control and limit complications.
